Basic Information
| Provider Information | |||||||||
| NPI: | 1376854661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDICAL RESOURCES GROUP NURSE PRACTITIONERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 LIVERNOIS RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2486808031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 LIVERNOIS RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486808000 | ||||||||
| FaxNumber: | 2486808031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2010 | ||||||||
| LastUpdateDate: | 01/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2486808206 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.